Mr David ChungEmergency Medicine

NHS Ayrshire and Arran

When are the following full?

• 23 Bedded Medical Admissions Unit• 5 Bedded ITU• Operating Theatres

Guess the disease

• Which disease will, when it is in season do the following?– Increase Inpatient mortality by 20%– Increase Inpatient Length of Stay by 1-3 days– Increase likelihood of errors– Increase complaints and litigation.

Emergency Department Crowding

What Is Emergency Medicine

• 'Emergency Medicine - A service with the expertise to assess and manage undifferentiated patients when the urgency of presentation is such that no appropriate alternative arrangements can be made'

What is an Emergency Department?

• Best to think of it in 3 main bits– Majors Stream (Emergencies and Accidents)– Minors Stream (Accidents and convenience)– Paeds (Accidents, Anxiety and Emergencies)

• Sometimes other bits like CDU and Clinics

Crowding

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Current model

The Mortality Bit Richardson; In a single ED, RR of mortality at 10 days was 1.34 (95% CI = 1.04 to

1.72) when hospital and ED crowded.

Sprivulis; In three hospitals, hazard ratios for mortality at 2, 7, and 30 days were 1.3, 1.3, and 1.2 for patients admitted during periods of greater ED and hospital occupancy.

Miro; In a single ED, weekly visit volume and ED mortality rate correlated (p = 0.01).

Chalfin; In a consortium of 120 hospital ICUs, in-hospital mortality when transferred to ICU > 6 hours was 17.4% vs. 12.9% for transferred < 6 hours (OR = 0.71; 95% CI = 0.56 to 0.89).

When ED Majors is Full, it’s Crowded

• Crowding is usually caused by boarding.

Boarding?

• ACEM Definition– Any patient waiting more than 2 hours for an

inpatient bed after the decision to admit is made

What Causes Crowding?

• Boarders cause Crowding• Boarders are caused by increased Hospital

Occupancy– This can be due to increased admissions– It could be due to decreased discharges– It could be due to reduced capacity– Or All 3

Why Minors don’t matter

• Because they can walk, and they usually leave.

• Capacity in ED has 3 components– Space (no of cubicles)– Time – Staff

Space and time

• No of cubicles X hours in day = Cubicle Hours (CH)

• 0000-0800, not a lot going on, esp for admissions

• For admissions it’s an 18hr day (0800-0000), so it’s majors cubicles X 18 Cubicle Hours (CH)

Useful capacity

• For me that’s 13 X 18 = 234 CH• That’s 58.5 admissions with an average

journey time of 4 hours.

The effect of Boarders

• 1 x 12hr bed wait creates 12 wasted CH.• To get that capacity back, you would need to

see, for example, 24 other patients 30 mins quicker.

• Or redirect 12 patients from minors altogether

What’s happening now.

The average ED Journey time is increasing, esp for admissions.

• 60 admissions, 3hr journey = 180 CH• 60 admissions, 4 hr journey = 240 CH• QUARTER OF CAPACITY LOST• That’s 120 minors with 30 min shaved off to

compensate for the lost capacity• Or 60 redirections from minors a day

• The only thing that will work is sorting out waits for a bed

• If capacity is unchanged, the only way to deal with the increased numbers of admissions is to reduce the time they spend in the ED, or they will cause crowding.

Solutions, Low Cost, High Yield

• Early Discharge• 7 Day working week• Stable GP referrals don’t go to ED• Full Capacity Protocol

Full Capacity Protocol

• Introduced from the top in New York State in response to occupancy crisis in 2002

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“Radically” new model – redistribute the load

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Move SOME boarders to the floors, even if it means putting them in the hallway. The ED CONTINUES to bear brunt of boarders

Less People Will Die!

• After 4 years, and 55000 patients, of whom 2042 went to a hallway;– In hospital mortality, 2.5% (95%CI 2.5-2.7)in bed

vs 1.1% (95%CI 0.7-1.7) in hallway.– ICU transfers 6.7% (95% CI 6.5-6.9) in bed vs 2.5%

in hallway (95%CI 1.9-3.3)

Interesting observations

• 25% of patients in Hallways had a bed by the time they got to the ward

• 25% more got a bed on the ward within 60 mins of arrival.

This is just some mickey mouse outfit!

• Stony Brook• Duke• Wm. Beaumont• Yale• St. Barnabus system• NYU

What really needs to happen

• Acknowledge current model increases mortality, and we are choosing this over a model shown to be safe.• We are choosing the unsafe option

What else

• Appreciation that a crowded hospital and ED can result in preventable death.

• HSMR and investigations into this must acknowledge this fact.

• Similar to HAI

Refusal to alter behaviour to improve flow, and reduce unnecessary crowding is life threatening to patients and must be dealt with in that context

How I would do it.

• Stable GP patients don’t go to the ED• Eliminate Waste• Use the FCP as the driver of change.• Take the current financial resource paid for

out of hours and ensure that is where it is spent.

• This is about preventable mortality, not targets.

Is he finished?